<div class="page-head">
    <h3><?php echo Mage::helper('contactus')->__('Data Capture') ?></h3>
</div>
<div id="messages_product_view"><?php echo $this->getMessagesBlock()->getGroupedHtml() ?></div>

<div class="padder">
	<form action="<?php echo $this->getFormAction(); ?>" id="contactForm" method="post">
		<div class="head-alt2">
		    <h4 class="title"><?php echo $this->__('Contact Information') ?></h4>
		</div>
		<div>
		<?php echo $this->getChildHtml('cms_contactusblock');?>
		<p class="required"><?php echo $this->__('* Required Fields') ?></p>
		</div>
	    <fieldset class="group-select">
		<ul>
		<li>
			<div class="cu-input-box">
			    <label for="title" style="display:inline"><?php echo Mage::helper('contactus')->__('TITLE') ?></label>
			    <!--<input name="title" id="title" title="<?php echo $this->__('TITLE') ?>" value="" class="cu-input-text" type="text"/>-->
			    <input type="radio" name="title" id="titlemr" value="Mr" /><span><?php echo Mage::helper('contactus')->__('Mr') ?></span>
			    <input type="radio" name="title" id="titlemrs" value="Mrs" /><span><?php echo Mage::helper('contactus')->__('Mrs') ?></span>
			    <input type="radio" name="title" id="titlemiss" value="Miss" /><span><?php echo Mage::helper('contactus')->__('Miss') ?></span>
			    <input type="radio" name="title" id="titlems" value="Ms" /><span><?php echo Mage::helper('contactus')->__('Ms') ?></span>
			</div>
			
			<div class="cu-input-box">
			    <label for="surname"><?php echo Mage::helper('contactus')->__('SURNAME') ?> </label>
			    <input name="surname" id="surname" title="<?php echo $this->__('SURNAME') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			<div class="cu-input-box">
			    <label for="forename"><?php echo Mage::helper('contactus')->__('FORENAME') ?> </label>
			    <input name="forename" id="forename" title="<?php echo $this->__('FORENAME') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			<div class="cu-input-box">
			    <label for="address"><?php echo Mage::helper('contactus')->__('ADDRESS') ?> </label>
			    <input name="address" id="address" title="<?php echo $this->__('ADDRESS') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			<div class="cu-input-box">
			    <label for="postcode"><?php echo Mage::helper('contactus')->__('POSTCODE') ?></label>
			    <input name="postcode" id="postcode" title="<?php echo $this->__('POSTCODE') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			<div class="cu-input-box">
			    <label for="telephoneday"><?php echo Mage::helper('contactus')->__('TELEPHONE No.') ?> <span><?php echo Mage::helper('contactus')->__('(day)') ?></span></label>
			    <input name="telephoneday" id="telephoneday" title="<?php echo $this->__('TELEPHONE No.') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			<div class="cu-input-box">
			    <label for="telephonemob"><?php echo Mage::helper('contactus')->__('TELEPHONE No.') ?> <span><?php echo Mage::helper('contactus')->__('(mobile)') ?></span></label>
			    <input name="telephonemob" id="telephonemob" title="<?php echo $this->__('TELEPHONE No.') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			<div class="cu-input-box">
			    <label for="dob"><?php echo Mage::helper('contactus')->__('D.O.B') ?> </label>
			    <input name="dob" id="dob" title="<?php echo $this->__('D.O.B') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			<div class="cu-input-box">
			    <label for="email"><?php echo Mage::helper('contactus')->__('EMAIL') ?> </label><span class="required">*</span>
			    <input name="email" id="email" title="<?php echo $this->__('EMAIL') ?>" value="" class="required-entry cu-input-text validate-email" type="text"/>
			</div>
			<div class="clear"></div>
			<div class="input-box-background">
			<div style="padding:10px;">
			    <label for="pricedraw"><?php echo Mage::helper('contactus')->__('Prize Draw Entry Question:') ?></label>
			    <span><?php echo Mage::helper('contactus')->__('(please tick your choosen answer below:)') ?></span><br />
			    <span><?php echo Mage::helper('contactus')->__('Q: Which male actor starred alongside Olivia Newton John in the film Grease?') ?></span><br />
			    <span><?php echo Mage::helper('contactus')->__('A: Was it') ?></span>
			    <span><?php echo Mage::helper('contactus')->__('a) John Travolta') ?></span>
			    <input name="pricedrawa" id="pricedrawa" title="<?php echo $this->__('a) John Travolta') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('b) Patrick Swayze') ?></span>
			    <input name="pricedrawb" id="pricedrawb" title="<?php echo $this->__('b) Patrick Swayze') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('c) Robert Redford') ?></span>
			    <input name="pricedrawc" id="pricedrawc" title="<?php echo $this->__('c) Robert Redford') ?>" value="1" type="checkbox"/>
			</div>
			</div>
			
			<div class="cu-input-box">
				<input type="checkbox" name="confirm18" title="<?php echo $this->__('I confirm I am over 18yrs of age, hold a full driving licence and would be available to collect the prize car before 31st December 2008') ?>" value="1" id="confirm18" />
				<label for="confirm18"><?php echo $this->__('I confirm I am over 18yrs of age, hold a full driving licence and would be available to collect the prize car before 31st December 2008') ?></label>
			</div>
			<div class="clear"></div>
	    </li>
	    <li>
			<div class="cu-input-box">
			    <label for="carsinhouse"><?php echo Mage::helper('contactus')->__('How many cars in your household?') ?></label>
			    <input name="carsinhouse" id="carsinhouse" title="<?php echo $this->__('How many cars in your household?') ?>" value="" class="cu-input-text" type="text"/>
			</div>
			
			<div class="cu-input-box">
			    <label for="cardrive"><?php echo Mage::helper('contactus')->__('What car do you drive?') ?> </label><br />
			    <span><?php echo Mage::helper('contactus')->__('MAKE:') ?></span>
			    <input name="cardrivemake" id="cardrivemake" title="<?php echo $this->__('MAKE:') ?>" value="" class="cu-input-text" type="text" style="width:80px;"/>
			    <span><?php echo Mage::helper('contactus')->__('MODEL:') ?></span>
			    <input name="cardrivemodel" id="cardrivemodel" title="<?php echo $this->__('MODEL:') ?>" value="" class="cu-input-text" type="text" style="width:80px;"/>
			    <span><?php echo Mage::helper('contactus')->__('YEAR:') ?></span>
			    <input name="cardriveyear" id="cardriveyear" title="<?php echo $this->__('YEAR:') ?>" value="" class="cu-input-text" type="text" style="width:80px;"/>
			    <span><?php echo Mage::helper('contactus')->__('COLOUR:') ?></span>
			    <input name="cardrivecolour" id="cardrivecolour" title="<?php echo $this->__('COLOUR:') ?>" value="" class="cu-input-text" type="text" style="width:80px;"/>			
			</div>
			<div class="clear"></div>
		</li>
	    <li>
			<div class="cu-input-box">
			    <label for="bought"><?php echo Mage::helper('contactus')->__('Which of the following Greased Lightning products have you bought recently?') ?></label>
			    <span><?php echo Mage::helper('contactus')->__('(tick as appropriate)') ?></span><br />

				<input name="bought1" id="bought1" title="<?php echo $this->__('Spray & Shine') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Spray & Shine') ?></span>
				<input name="bought2" id="bought2" title="<?php echo $this->__('Spray & Clean') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Spray & Clean') ?></span>
			    <input name="bought3" id="bought3" title="<?php echo $this->__('Tyre & Trim') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Tyre & Trim') ?></span>
			    <input name="bought4" id="bought4" title="<?php echo $this->__('No Fog') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('No Fog') ?></span><br/>
			    <input name="bought5" id="bought5" title="<?php echo $this->__('Rain Away') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Rain Away') ?></span>
			    <input name="bought6" id="bought6" title="<?php echo $this->__('Engine Treatment') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Engine Treatment') ?></span>
			    <input name="bought7" id="bought7" title="<?php echo $this->__('Fuel System Treatment') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Fuel System Treatment') ?></span><br/>
			    <input name="bought8" id="bought8" title="<?php echo $this->__('Wheelshield') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Wheelshield') ?></span>
			    <input name="bought9" id="bought9" title="<?php echo $this->__('Windscreen Washer Tablets') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Windscreen Washer Tablets') ?></span>
			    <input name="bought10" id="bought10" title="<?php echo $this->__('Miracle Cloth(s)') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Miracle Cloth(s)') ?></span><br/>
			    <input name="bought11" id="bought11" title="<?php echo $this->__('Promotional Pack') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Promotional Pack') ?></span>
			    <input name="bought12" id="bought12" title="<?php echo $this->__('Other (please specify)') ?>" value="1" type="checkbox"/>
			    <span><?php echo Mage::helper('contactus')->__('Other (please specify)') ?></span>
		    
			</div>
			
			<div class="cu-input-box">
			    <label for="favourite"><?php echo Mage::helper('contactus')->__('What is your favourite Greased Lightning product') ?></label>
			    <input name="favourite" id="favourite" title="<?php echo $this->__('What is your favourite Greased Lightning product') ?>" value="" class="cu-input-text" type="text"/>
			</div>

			<div class="clear"></div>

	    </li>
	    <li>
			
			<div class="cu-input-box">
				<input type="checkbox" name="keptinformed" title="<?php echo $this->__('I wish to be kept informed of promotional offers and activity by Greased Lightning and / or Ideal World') ?>" value="1" id="keptinformed" />
				<label for="keptinformed"><?php echo $this->__('I wish to be kept informed of promotional offers and activity by Greased Lightning and / or Ideal World') ?></label>
			</div>
			
		</li>
		</ul>
	    </fieldset>
	    <div class="button-set">
		<input type="image" src="<?php echo $this->getSkinUrl('images/btn_submit.gif');?>" alt="<?php echo $this->__('Submit') ?>"/>
	    </div>
	</form>
	<script type="text/javascript">
	    var contactForm = new VarienForm('contactForm', true);
	</script>
</div>